Various studies have shown that the accuracy of dose delivery is affected by a number of factors, including: injection methodologies employed by medical practitioners, an inability to accurately read and control plunger travel during dosing, and the loss of dosage associated with the prime step used to evacuate air from the syringe prior to the dosing step. These effects are particularly magnified by the use of drug delivery syringes that have a high dose volume to axial translation ratio (i.e., a significant quantity of drug is dispensed for even incrementally small distances of plunger depression, as may be the case for large diameter syringes); this problem is more acute when delivering microliter size doses. While these causes for error are common, the need for accurate dose syringes remains. Such syringes are of particular importance in sensitive operations, such as in intravitreal injections, and are very desirable for low dose treatments where inaccurate dosing can lead to substantial error and potential patient harm.
Studies have shown that the amount of treatment delivered may vary significantly depending on whether the medical practitioner chooses to deliver 5 μL (5 microliters) of the treatment by depressing the syringe plunger from 10 μL to 5 μL or by depressing the syringe from 5 μL to 0 μL. Additionally, due to the uncertainty of plunger travel limits some practitioners may depress the syringe past the natural travel limit and deliver excess treatment to the patient because of mechanical compliance between the stopper and the syringe barrel. For example, given a particular syringe barrel diameter, a practitioner may depress the plunger past the natural stop for 0 μL and erroneously deliver up to 20% more dosage than necessary. This error is magnified because of the small dose volume requirements for particular treatments. Because the dosage amount and associated plunger travel distance are small, it is very difficult for a practitioner to gauge the fill amount of the dosing chamber and to control the injection amount as the treatment is applied to the patient. This inaccuracy in dosing can lead to substantial safety risks including, among other side effects, increased pressure in the target region and altered (reduced) drug efficacy.
A primary cause of the dosing inaccuracy is the inability to reliably set the limits of plunger travel, and the inherent variability in the degree to which the plunger seal (or stopper) is depressed at end of delivery during dosing. Also contributing to inaccuracy is the potential variability, during syringe manufacturing, in the placement of reference markings on the syringe barrel. Endemic to these causes of inaccuracy is the high sensitivity of volume dispensed to the axial travel of the plunger, as described above. Mechanical travel limits, however, are difficult to employ in such applications because of the challenges associated with reading and controlling the plunger travel by the user over the small distance of dosing. Simply put, because the dosage amounts are so small, it is difficult for a practitioner to identify the dosage measurements on the syringe barrel and accurately control the plunger depression and dosage amount during injection.
In addition to improving dosing accuracy, it is useful to incorporate the functionality of a priming step into a syringe design to reduce or eliminate air bubbles within the dosing chamber. This step is very useful to minimize safety risks, improve operational hygiene, and reduce pressure in the target site. Minimizing the likelihood of air bubbles during filling helps streamline the drug delivery process for the clinician. Employing pre-filled syringes may assist in the minimization of air bubbles. However, even pre-filled syringes are not fully devoid of air captured during the filling process.
Accordingly, there is a substantial need for syringes which allow the user to readily identify and control the dosage amount, minimize the presence of air bubbles within the dosage chamber prior to drug delivery, and ensure accurate delivery of the required drug dose. It is preferred that such a syringe would enable pre-filling to take advantage of benefits associated with the use of such products.
Further, some medications require mixing two fluids or reconstitution of dry or lyophilized drug prior to an accurate dose injection. This allows, for example, a diluent to be added to a dehydrated, lyophilized, desiccated or powdered active substance immediately prior to injection, which is particularly useful for substances that are subject to degradation or loss of activity when stored in a hydrated form. This also allows for mixing of two liquids, which are mixed just before an injection.While it is known to provide syringes that comprise a mixing device for mixing deliverable substances prior to injection, the market has been unable to provide such mixing syringes that are capable of providing accurate dosage delivery required for some medications and as discussed above. Examples of such mixing syringes are disclosed, for example, in U.S. patent application Ser. No. 13/566,079, which is assigned to the assignee of this disclosure and incorporated by reference. In addition to the complexities of the structures themselves, the designs may require complex assemblies, multiple operation steps by the user, or other particular nuances that make them difficult to manufacture, assemble, or operate. Further, some mixing syringes must also address factors such as maintenance of container sterility, interaction of components for sealing, venting requirements, and distribution of internal forces, among others. Each of these challenges is further complicated when extreme dose accuracy is required.